If you are an existing patient needing help, we have a few options for you.
1. Use our patient portal.
2. OR – Call us at 630-371-9980
3. OR – If you are having any difficulty with the phone system, please email at PatientHelp@painchicago.com
4. OR – fill out the following form:
Please complete pain diagram and bring to your appointment. If there are any Demographic/Insurance changes or HIPAA updates, please complete and bring to your appointment. Thank you.
- Patient Demographics
- Signature Sheet
- Pain Diagram
- HIPAA Form
- ARI Form
- Insurance Communications Consent (ICC)
- COVID 19 Consent Form
- Requisition for Forms – FMLA and Other
- Authorization for Release of Medical Records
(Please complete a request for form and fax it to our office at 630-371-1555. There is a 10 business day turnaround time)
- Self Pay Policy Form
- New Patient Packet
- MR Release Form
- Curbside Office Visit Instructions
- Request Medical Records
- Benefits Assignment Policy
- ICC (Portal)
- Interventional Procedure Instructions
- Notice of Privacy Practices
- Opioid Policy
- Controlled Substance Agreement
- Opioid Consent for Treatment
- Controlled Substance Policy
I want to "Thank You" for controlling my pain. I want to thank you for the opportunity to see my two children graduate college and then go on to achieve their master's degrees. We now live in Texas with our two children and our two grandchildren. We will be moving into our new home in about three weeks.
I had back pain so bad I couldn’t walk. I tried a chiropractor but got no relief. My husband has been using Dr. Glaser for years and suggested I go see him. I went and have never been happier that I did. I am pain free!!!! Also, I’d like to say that the office staff was very good too.
Learn about our 72 Hour Commitment to your pain relief.
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